Access to Sexual and Reproductive Health Services

 

Welcome to the programmatic area on access to sexual and reproductive health (SRH) services within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the service delivery section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. A primary strategy of health programs is to increase access to services.  Different approaches to increasing access include establishing additional facilities, training more health workers, increasing outreach activities, and so forth. Access to services is not merely an issue of physical distance, but one that involves other factors as well. The indicators presented in this database measure access along multiple dimensions: geographical/physical, economic, administrative, and psychosocial. Key indicators to monitor and evaluate access to services can be found in the links at left.   Full Text A primary strategy of health programs is to increase access to services.  Different approaches to increasing access include establishing additional facilities, training more health workers, increasing outreach activities, and so forth. Despite the widely acknowledged importance of access as a key feature of the supply environment, this factor is not routinely assessed in reproductive health (RH) program evaluation. Much of the previous research in this area has focused on one aspect or dimension of accessibility: geographic (or physical) access.  In this context, access (or accessibility) refers to the degree of difficulty in reaching or obtaining RH services.  Researchers have proposed a variety of measures pertaining to the distance to supply and to service points, the time required to reach these points, and the density of service/supply points within a specified geographic area.  In the case of family planning, the evidence to date tends to confirm the relevance of geographic proximity to contraceptive services as an important determinant of contraceptive use. Some researchers have distinguished between the terms "availability" (to describe whether a particular method or service is provided) and "accessibility" (to denote a continuum of effort required to obtain services) [Bertrand et al., 1995].  However, the terms are often used interchangeably, and in this database, "access" is used to reflect the degree of difficulty (or ease) in accessing services. Access to services is not merely an issue of physical distance, but one that involves other dimensions as well (Chavoyan, Hermalin, and Knodel, 1984; Foreit et al., 1978).  Foreit et al. suggested the following as relevant dimensions or elements of accessibility (the authors used the term "availability" in the original text): geographic or physical, economic, administrative, and cognitive. The indicators that follow measure access along multiple dimensions: geographical/ physical, economic, administrative, and psychosocial. __________ References: Bertrand, J.T., K. Hardee, R. Magnani, and M. Angle. 1995. "Access, Quality of Care and Medical Barriers In Family Planning Programs." International Family Planning Perspectives 21, 2: 64-69,74. Chayovan, N., A. I. Hermalin, and J. Knodel. 1984. "Measuring Accessibility to Family Planning Services in Thailand." Studies in Family Planning 15, 5:201-211. Foreit, J.R., M.E. Gorosh, D.G. Gillespie, and C.G. Merritt. 1978. "Community-based and Commercial Contraceptive Distribution: An Inventory and Appraisal." Population Reports Series J, 19, March: J1-J29.

Existence of national laws, regulations, or policies that limit access to effective family planning services for unmarried and/or young people

Definition:

 

The existence of national laws, regulations, or policies that limit access to effective family planning (FP) services for specific populations (e.g. single women, women without children, youth, etc.) as a result of gender inequitable stereotypes and/or cultural norms. The existence of the national laws, regulations, or policies must be verified.  Effective FP services refers to distribution of modern FP methods (e.g., condoms, pills, implants, etc.), accurate and informative counseling, and referrals.  Young people, as defined by the WHO, comprises those age 10-24 years.

Data Requirements:

Text of formal law or policy; evidence of official acceptance of law, regulation, or policy; reports of dissemination and implementation of law, regulation or policy

Data Sources:

Public laws and official government documents; newspaper articles, government communiques or other public expressions; interviews with government officials; interviews with FP program managers and/or providers; health institutions' policies and regulations

Purpose:

This output indicator is an assessment of the legal/regulatory environment that restricts users, and as such, is a measure of the degree to which national policy supports or hinders universal access to FP, fertility decline, and the rights of unmarried and/or young people to reproductive choice and information.  It serves as a valuable baseline for the evaluation of national FP policy development and support.  A more restrictive policy environment is correlated with decreased service utilization and contraceptive use.  It influences service delivery with respect to access, quality, and FP image, and may have indirect effects on overall FP demand.

Issue(s):

This is a qualitative (yes/no) indicator. It does not describe the law/regulation/policy that exists, nor does it indicate the extent to which effective provision of FP services is limited, how it is limited, or whether providers/pharmacies follow the regulation. Because this indicator only verifies legal statutes and not actual provider practices and biases, it alone cannot determine the full extent to access barriers for unmarried and/or young people. Furthermore, it does not indicate the number of national regulations that exist, nor if they exist solely in the private versus public sector. Finally, without knowing about the dissemination or implementation of the regulations that may exist, it is difficult to appreciate their impact on the population and on the use of contraception.

Gender Implications:

 

In many cultures, traditional gender roles hold double standards for males and females, dictating that sex is seen as a place for men – and is often accepted as a way for young men to prove their masculinity – but is considered immoral or shameful for young women, particularly outside of marriage (Marin, 2003).  When this moral judgment becomes institutionalized into law, restrictive access to effective FP services further stigmatizes unmarried, sexually active women and can have serious negative health consequences with regard to early pregnancy, unwanted pregnancy, and sexually transmitted infections.

References:

 

Bertrand JT, Magnani RJ, Rutenberg. Handbook of indicators for family planning program evaluation 1994. The Evaluation Project. USAID Contract Number: DPE-3060-C-00-1054-00. Accessed at: https://www.measureevaluation.org/resources/publications/ms-94-01

Marin, B. 2003.  “HIV Prevention in the Hispanic Community: Sex, Culture, and Empowerment.” Journal of Transcultural Nursing 14:3, 186-192.

Percent of population living within two hours travel time from nearest facility offering a specific reproductive health service

Definition:

The percent of the population in a given geographical area that resides within two hours travel to the nearest service delivery site offering a specific type of reproductive health (RH) service (e.g., antenatal care, voluntary counseling and testing, male sterilization)

The time (measured in minutes) is contextually-based and depends on what the most common form of transportation is.  For example, at one site, traveling may be primarily on foot whereas at another site it may be by motorbike and vehicle.

This indicator is calculated as:

(Number of respondents living within two hours travel time to nearest facility providing a specific RH service / Total number of people surveyed) x 100

Data Requirements:

Information on the location of the respondents in relation to the service delivery point in question

One can map the routes between a given community and an individual service delivery point and can (preferably) obtain measures of travel time. 

Self-reports of respondents or key informants is another way to determine travel time.

Data Sources:

Data from facility-based surveys analyzed in relation to data from household surveys (e.g., in the context of a DHS survey); special surveys

Purpose:

Ideally, the researcher will determine the distance between the home of an average citizen in country X and the nearest facility providing a specific RH service and with that information, determine the time it takes to cover that distance by the most common mode(s) of transportation. In the past, researchers often relied on self-report of survey respondents or of community informants, both of which tended to be highly unreliable. In recent years, researchers have attempted to link the DHS household surveys with surveys of the facilities in the surrounding area in selected countries. In linking the data from the household and facility-based surveys, researchers and evaluators are able to accurately measure distance between these communities and service delivery points (Akin et al., 1998; Seiber and Bertrand, 2001).

Issue(s):

There are, however, several caveats to measuring access using this linking technique. First, many DHS household surveys do not include a facility-based survey, or the facility-based survey is not linked to the household survey. Second, the human and financial resources needed to carry out a DHS with both the household and the facility-based components are considerable. Thus, in the best of cases, the linked surveys are conducted only once every 3-5 years. Third, this linking of the two surveys allows for a much more precise measurement of the time and distance between the household of the average respondent and the nearest service delivery point. However, research has shown that clients often elect to use services at some more distant point to preserve their privacy; to obtain a range of services (e.g., specific contraceptive method, or special lab procedures) not available at a facility closer to their home; or to obtain higher quality services (e.g., better client-provider communication).

To date, evaluators have studied physical access as a determinant of service utilization and use, but program managers have not routinely used it for the day-to-day monitoring of program performance, because of the time and expense associated with the above-mentioned linking procedure.

Gender Implications:

Distance to the nearest RH facility represents, on one hand, the commitment and resources of government to provide universal access to health care. It is an important variable to consider in terms of women's ability to obtain obstetrical services-- maternal and child health care and family planning-- particularly in areas where transportation is difficult. Distance to needed obstetrical services and lack of transport to reach a facility offering such services are key variables contributing to maternal deaths. Advocates for safe motherhood argue that these preventable deaths indicate that policy makers undervalue women's lives. Advocates employ human rights conventions to hold governments accountable for providing appropriate and accessible health services (Rosenfield, 2001). On the other hand, when women travel outside of their communities to obtain care at a remote service site, they may do so because some service facilities fail to adequately observe privacy and confidentiality, and women fear the consequences. For example, women who feel they must obtain contraceptives covertly because of perceived disapproval on the part of the husband or extended family may fear retribution if confidentiality is violated. Many small local service outlets have no potential for offering women visual privacy as they wait in line for services. However, even these facilities can observe policies and procedures to protect the woman's confidentiality in RH choices and services obtained.

References:

Akin J.S., D.K. Guilkey, P.L. Hutchinson, and M.T. McIntosh. 1998. "Price Elasticities of Demand for Curative Health Care with Control for Sample Selectivity on Endogenous Illness: An Analysis for Sri Lanka." Health Economics 7, 509-531.

Rosenfield A, 2001. "Maternal Mortality as a Human Rights and Gender Issue". In: Reproductive Health, Gender and Human Rights: a dialogue. Edited by Elaine Murphy and Karin Ringheim. Washington D.C.: Program for Appropriate Technology in Health [PATH].

Seiber, E. and J.T. Bertrand. 2001. "Access as a Factor in Differential Contraceptive Use between Mayans and Ladinos in Guatemala." MEASURE Evaluation Project Working Paper Series. University of North Carolina, Chapel Hill, NC: Carolina Population Center.

Number of service facilities offering a specific reproductive health service per 500,000 people

Definition:

In a given population of half a million people, the number of health facilities that provide a specific reproductive health (RH) service (e.g., contraceptives, postabortion care, voluntary counseling and testing, micronutrient supplementation)

Data Requirements:

Information on the total number of facilities offering a specific service and the total population (or relevant subgroup) in the catchment area.

Note: evaluators may limit the denominator to an estimate of the relevant sub-group for the service (e.g.,
all women of reproductive age for family planning, all pregnant women needing micronutrient supplementation, all adults 15 to 65 for HIV counseling and testing). Because of the difficulties associated with estimating the exact number of persons in need of such a service (e.g., postabortion care), evaluators may opt to use the total population in the denominator.

Data Sources:

Program records on the service delivery infrastructure; census data on size of population in the catchment area

Purpose:

This indicator gives a broad sense of the density of service delivery points for specific types of RH interventions. It can be useful for advocacy purposes in creating awareness of the deficiencies in the service delivery environment for particular services.

One potential use of this indicator is to help governments track progress in terms of improving the service delivery environment for the population. However crude this measure is (and how little it reflects the situation of a specific individual in that society), it does represent progress for a government to increase the number of RH facilities per 500,000 in the population (assuming quality remains constant or improves). Moreover, where data on the health service environment are fairly reliable, evaluators may collect this information at relatively little cost to the user.

Issue(s):

Caveats for this indicator include the following. First, although this indicator gives a ratio of service delivery points per population, it does not reflect the geographical distribution of such points. In the case where service delivery facilities cluster in urban areas, this indicator may yield a more favorable estimate of access to services than individuals in rural areas actually experience. Second, it is easier to collect information on the availability of some services than of others. For example, many countries have fairly accurate lists of family planning services through government or NGO facilities. However, they may not track the number of pharmacies that carry contraception and other RH products, and thus may underestimate the access of the population to these commodities. In more controversial subject areas, such as postabortion care, facilities may provide services but not publicize them widely, and thus may create undercounts on this indicator for those services. A third caveat is that services may exist "on paper" but not at the actual field site.

Cost of one month's supply of contraceptives as a percent of monthly wages

Definition:

"Costs" refer to out-of-pocket expenses for contraceptive supplies and services

This indicator is calculated as:

(Cost of one month's supply of contraceptives/ One month's wages) x 100

Data Requirements:

Information on monthly expenditures on contraceptive supplies and services and estimated monthly income

Data Sources:

Information from population-based surveys on service and supply costs; fees may also be available from facility records.

Purpose:

This indicator provides a measure of the relative economic burden represented by monthly service and supply costs of contraceptive use. This measure applies specifically to family planning (FP), but evaluators can adapt it to other areas of reproductive health by substituting the cost of the product in question for contraceptives in this definition.

Service and supply costs exceeding one percent of monthly wages for a significant proportion of clients may constitute an economic barrier to contraceptive use (Ross et al., 1992).

Issue(s):

The illustrative indicator for this element was chosen from among several alternatives in large part because the data required for its computation are the most likely among the alternatives to be available in a reasonably large number of developing country settings. However, evaluators should recognize that the indicator suffers from several important limitations.

One limitation is that the indicator ignores other costs of contraceptive use that may be just as, or perhaps more, important barriers to contraceptive use than direct service or supply costs are. For example, FP clients may also incur out-of-pocket expenses for transportation to and from the facility and (possibly) for child care, as well as opportunity costs of time spent traveling to and from the service delivery point and waiting for service or supplies once clients reach the facility. Thus, a more valid measure of the costs of FP services would also include these costs in the computation of the indicator.

Another issue concerns the stream of income that evaluators should consider in computing the indicator. Since not all income (gross income) is likely to be available for use in paying for contraceptive services, a more appropriate specification of the indicator will limit the denominator of the measure to monthly disposable income. Furthermore, since men and women do not have equal access to household financial resources in many societies, a further refinement may be to limit the denominator of the measure to income or wages controlled by the client (especially female clients).

Evaluators should recognize, however, that these refinements add to the data requirements for computing the indicator. In many countries, the required information may be available only from special studies. For most practical purposes, the simpler indicator should suffice to guide program management decisions regarding the affordability of contraceptive services. In programs where cost recovery and sustainability are priority management issues, however, the added costs of gathering data required for the more refined measures may be justified.

References:

Ross J.A., W.P. Mauldin, S.R. Green, and E.R Cooke. 1992. Family Planning and Child Survival Program, as Assessed in 1991. New York, NY: The Population Council

Percent of facilities with non-medical restrictive eligibility criteria

Definition:

Eligibility criteria of a non-medical nature, mandated by the service facility or organization, which limit access to reproductive health (RH) services for specific categories of individuals (e.g. youth, particularly unmarried females; commercial sex workers; individuals from a certain tribe or ethnic group; etc.)

This indicator is calculated as:

(# of facilities with non-medical restrictive eligibility criteria/ Total # of medical facilities) x100

 

Data Requirements:

Eligibility criteria for services offered by the program

Data Sources:

Program documents outlining policies and regulations; interviews with staff

Purpose:

This indicator identifies the existence of barriers to services in the form of unnecessary formal program policies, regulations, and procedures; such restrictions, mandated at the policy/program level, exceed those justified on medical grounds. Typical restrictive criteria for different RH services include the following:

Family Planning:


Sexually Transmitted Infections (STIs):

Maternal Health:

Adolescent Reproductive Health Services:

Abortion and Postabortion Care:

 

Administrative barriers to access occur less frequently for STI/HIV services, which tend to be provided to those who seek treatment.

Percent of non-use related to psycho-social barriers

Definition:

The proportion of women who want to use a reproductive health (RH) service who avoid use because of barriers of a psychosocial nature; for example, fear (of negative social stigma, embarrassment, discomfort) or social restrictions (e.g., against women traveling alone to seek services)

This indicator focuses on factors that deter a woman or man who wants to use a certain service or practice from doing so. For example, adolescents wishing to obtain information and services from a local clinic might be deterred from doing so by fear of being seen at the clinic or being judged by friends to have low moral standards. A woman wanting to be tested for HIV might fear some type of violent reaction from her husband should he find out. Note: this indicator does not apply to the case where the individual is not even interested in the service.

This indicator is calculated as:

(# who report non-use due to psycho-social barriers/ Total # of clients seeking RH services) x 100

Data Requirements:

Information on reasons for non-use of services or RH practices among individuals interested in but avoiding a particular service or practice

Data Sources:

Population-based surveys; alternatively, focus group discussions (although they do not yield a quantitative result)

Purpose:

This indicator provides a measure of the extent to which access to available RH services is limited by barriers of psychological, attitudinal, or social origin.

Issue(s):

Given the context-specific nature of factors falling under this heading, the reasons for non-use of services will likely vary from setting to setting. Thus, the exact numerical figure associated with a particular barrier or factor may be less important than the rank ordering of problems. In view of this, data from focus groups (that do not provide results in quantitative terms such as percentages or ratios) may be more valuable in identifying barriers of this type than data derived from structured interviews are.

Percent of primary health care facilities providing family planning services

Definition:

The percent of primary health care facilities in a designated area that provide basic family planning (FP) services. Ideally, primary health care facilities include all public, private, non-governmental, and community-based facilities.

FP services should be available to men as well as women and to adolescents (with referral as required), and should include counseling, information, education, and method delivery and follow-up (WHO/UNFPA, 2008).  The basic package of FP methods available should include modern methods (e.g., hormonal contraceptives, IUDs), condoms, and counseling and/or referrals on fertility awareness methods, postpartum FP, and the lactational amenorrhea method, in addition to referrals for methods requiring higher levels of care, such as implants and sterilization. 

This indicator is calculated as:

(Number of primary care facilities providing FP services / Total number of primary care facilities in a designated area) x 100

Data Requirements:

Data can be used from facility records, health information systems (HIS), and specialized surveys, such as Health Facility Assessments (HFA) and the Service Provision Assessment Survey (SPA). For an overview of various HFA instruments, see MEASURE Evaluation/USAID/WHO (2008), and for SPA, see MEASURE DHS (2011). The data can be disaggregated by the type of facility or program (public, private, non-governmental, community-based), the types of FP methods and services available, and by other relevant factors such as districts and urban/rural location.

Data Sources:

Facility records; HIS; specialized surveys; HFA; SPA

Purpose:

This indicator measures access to FP methods through primary health care facilities and is included among the core access indicators for the achievement of universal access to reproductive health (RH) (WHO/UNFPA. 2008). Primary health care facilities, particularly community-based facilities, often serve low-income and marginalized populations and can be entry points for health care and for FP services. The provision of FP services at the primary care level is considered an essential part of achieving universal access and relates directly to Millennium Development Goals #5. improve maternal health and #4. reduce child mortality.

Issue(s):

While this indicator measures availability of FP services in primary health care facilities as a component of access, it does not capture specific aspects of or barriers to access, for example, physical availability, cost, method mix, supply, information, availability of trained providers, and quality of services.  For these purposes, data on utilization, travel time, hours of operation, costs of services, types of methods available, stock-outs, youth friendliness, staffing, and perceived quality of care can be beneficial.

The integration of FP services with primary health care can be more costly than providing them in stand-alone RH/FP clinics. However, the benefit of increasing client access and utilization of FP services can outweigh the added costs.

References:

MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm

MEASURE Evaluation/USAID/WHO, 2008, Profiles of Health Facility Assessment Methods: Report of the International Health Facility Assessment Network (IHFAN), Chapel Hill, NC: MEASURE Evaluation. http://www.cpc.unc.edu/measure/publications/tr-06-36

WHO/UNFPA, 2008, National-level monitoring of the achievement of universal access to reproductive health: conceptual and practical considerations and related indicators, Geneva: WHO. http://whqlibdoc.who.int/publications/2008/9789241596831_eng.pdf 

 

Service delivery points providing appropriate medical, psychological, and legal support for women and men who have been raped or experienced incest

Definition:

 

The number or percent of service delivery points (SDP) that provide medical, psychological, and legal support and/or referrals appropriate to meet the needs of females and males who have been raped or experienced incest.  SDPs can include health units of any type or level (public, private, non-governmental, community-based; primary, secondary or tertiary care) and facilities providing services specifically for victims of sexual and gender based violence (SGBV).

Appropriate services for survivors of rape and incest include identification of survivors, necessary medical services, counseling, and referrals to community-based resources such as legal aid, safe shelter and social services. For further detail on related indicators for SGBV, see Bloom (2008).     

This indicator is calculated as:

(Number of SDPs providing appropriate medical, psychological, and legal support for women and men who have experienced rape or incest / Total number of SDPs in a designated area) x 100

Data Requirements:

The indicator can be calculated using data from surveys of health care facilities or other SDPs that provide care for survivors of rape and incest. The survey can be part of a specific study on SGBV using standard assessments, such as IPPF, UNFPA/Ipas, and SVRI, or part of a more general study of health facilities and service provision. A probability sample of SDPs can be selected in order to assess services in the geographic area of interest. All SDPs that can answer questions affirmatively about provision of medical, psychological and legal support or referral services and/or show corresponding records documenting these services are included in the numerator. Data can be disaggregated by the type of facility or program (public, private, non-governmental, community-based; primary, secondary or tertiary); the range of services available, age and sex of clients, and by other relevant factors such as districts and urban/rural location.

Data Sources:

Facility records, specialized surveys with sections on facility and provider services, such as IPPF (2004), UNFPA/Ipas (2008) an SVRI (2008).

Purpose:

This indicator measures access to quality care for survivors of rape and incest across the range of health care facilities and SDPs. Short and long-term health risks from incest and rape for women and girls include gynecological problems, STDs, HIV/AIDS, early sexual experiences, early pregnancy, infertility, unwanted pregnancy, abortion, pelvic inflammatory disease, re-victimization, high-risk behaviors, depression, substance abuse, suicide, and death (Stevens, 2002). In turn, health risks for male victims can include infections, STDs, HIV/AIDS, re-victimization and/or victimizing others, high-risk behaviors, depression, substance abuse, suicide, and death. The provision of adequate care for survivors of rape and incest is vital in the prevention and response to SGBV. Clinic visits made by SGBV survivors present an opportunity to address and ameliorate the effects of violence, as well as help prevent future incidents. In order to help survivors and take advantage of these opportunities, health facilities and related SDPs need to be prepared to deliver appropriate services. This indicator relates to achieving Millennium Development Goals: #3. promote gender equality and empower women; #5. improve maternal health; and #6. combat HIV/AIDS.

Issue(s):

This indicator measures the availability of services for rape and incest survivors, but does not capture specific aspects of or barriers to access including physical availability (e.g., travel time, transportation and hours of operation), cost, medical supplies, information, referrals, and quality of services.

Gender Implications:

With the focus on women and girls being the victims of SGBV, males may be reluctant to seek out services because of cultural beliefs that boys and men cannot be victims. SDPs may be ill-equipped to address male survivors of SGBV, including lack of provider training in caring for males and fewer agencies and networks (e.g., shelters, legal or social services) accepting referrals of males.

References:

 

Bloom S., 2008, Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.  USAID, IGWG, and MEASURE Evaluation. https://www.cpc.unc.edu/measure/tools/gender/violence-against-women-and-girls-compendium-of-indicators

International Planned Parenthood Federation, 2004, Improving the health sector response to gender-based violence: A resource manual for health care professionals in developing countries, IPPF/WHR Tools/02/September 2004. http://www.ippfwhr.org/sites/default/files/GBV_cdbookletANDmanual_FA_FINAL.pdf

Stevens, L. 2002. ‘A practical approach to gender-based violence: A programme guide for health care providers and managers’ developed by the UN Population Fund. Int. J of Gyn & Obstet. 78 (Suppl. 1): S111-S117. http://www.unfpa.org/webdav/site/global/shared/documents/publications/2001/genderbased_eng.pdf

Sexual Violence Research Initiative. 2008. Assessment Instruments Used to Study Healthcare-Based Interventions for Women Who Have Experienced Sexual Violence. Available at: http://www.svri.org/evaluation.htm

UNFPA/Ipas, 2008, Getting it Right! A practical guide to evaluating and improving health services for women victims and survivors of sexual violence, Chapel Hill, NC: Ipas.  www.ipas.org/~/media/Files/Ipas%20Publications/SVGUIDEE08

Number of communities with established referral systems between the community and primary, secondary, and tertiary resources for reproductive health services

Definition:

Indicator guidance to be developed.

Number/percent of clients referred to other reproductive health services

Definition:

Indicator guidance to be developed.

Service Availability and Readiness Assessment (SARA)

Definition:

The Service Availability and Readiness Assessment (SARA) is designed as a systematic survey to generate a set of core indicators of services, which can be used to measure progress in health system strengthening over time.  The SARA core indicators are incorporated into the inventory component of the Service Provision Assessment (SPA) survey as well.  The SARA focuses on service availability, general service readiness, and service-specific readiness.

Service availability refers to the physical presence of the delivery of services, encompassing the health infrastructure, core health personnel, and service utilization. This does not include more complex dimensions such as geographic barriers, travel time, and user behavior, which require more complex input data.

General service readiness is the overall capacity of health facilities to provide general health services. Readiness is defined as the availability of components required to provide services such as basic amenities, basic equipment, standard precautions, laboratory tests, and medicines and commodities.

Service-specific readiness is the ability of health facilities to offer a specific service and the capacity to provide that service measured through selected tracer items that include trained staff, guidelines, equipment, diagnostic capacity, and medicines and commodities.

Data Requirements:

The SARA core indicators are collected using an inventory format relying on key informant interviews and observation of items in a facility. These data are comparable both across countries and within countries (i.e, across regions and/or districts). To achieve this, a standard core questionnaire has been developed. Typically, a country adopts the core questionnaire with adaptations to certain country-specific elements.

Data Sources:

Interviews with the person in charge of the facility, or most senior health worker who is present at the facility and observation of items in a facility.

Purpose:

SARA is a health facility assessment tool designed to assess and monitor the service availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system. The SARA survey objective is to generate reliable and regular information on service delivery (such as the availability of key human and infrastructure resources), on the availability of basic equipment, basic amenities, essential medicines, and diagnostic capacities, and on the readiness of health facilities to provide basic health-care interventions relating to family planning, child health services, basic and comprehensive emergency obstetric care, HIV, TB, malaria, and non-communicable diseases.

Issue(s):

Although the service availability information is collected through the SARA questionnaire, these indicators should not be calculated for a sample of facilities; data must be available for ALL facilities in an administrative unit in order to calculate service availability. All service availability measures require data that link the numerator (e.g. number of facilities) to the denominator (population size).  Thus, a sample survey would not allow computation of the service availability indicators, as it is not clear what the corresponding population size to be used as the denominator should be. The information needed to calculate service availability can be gathered from multiple sources in addition to the SARA, namely a country’s health management information system (HMIS) and other routine information systems, and should be collated for all facilities before calculating the service availability indicators. If the SARA is implemented as a census, then it can be used to calculate service availability.

The tool does not attempt to measure the quality of services or resources, but it can be used in conjunction with additional modules such as management assessment, quality of care, etc.

References:

Service Availability and Readiness Assessment (SARA)